Oncology emergencies
Mass effect
Bone mets and pathologic fracture
Spinal cord compression
Sites
Thoracic vertebrae are most common with ~10% of noncontiguous mets at other vertebra -> whole spine imaging for survey (C-spine mets is uncommon, some may preclude its imaging if lack of sx)
Pericardial effusion with tamponade
Treatment
Reduce edema and inflammation
Dexamethasone 10mg IV -> 4mg PO/IV Q6H (do not wait until imaging if highly suspected)
Pain control
Reduce tumor size
Emergent radiotherapy (~90% ambulatory remains ambulatory; 50% cannot walk alone regain ambulation; a few with paraplegia regain LE function)
High risk cancer types
lung, breast, melanoma, leukemia, lymphoma; also postR/T, C/T
SVC syndrome (usually increase jugular venous pressure from 2~8 to 20~40mmHg); develops dilatation of collateral venous system for venous return
Causes
Cancer extrinsic compression
70% lung, 20% lymphoma
iatrogenic
indwelling catheter placement, pacemaker leads
Treatment
Reduce venous congestion
head elevation (to decrease ICP)
Corticosteroid, loop diuretics (insig clinical efficience)
make a hole
intravascular stent
Reduce tumor size
chemotherapy (relief sx in 80% of lymphoma, 80% of SCLC, 40% of NSCLC)
radiotherapy (relief sx in 75% at D3)
Airway obstruction
Biochemical derangement
Hypercalcemia
mechanism
PTH related protein production
osteoclastic activity, such as w/ bone mets
vit D analogue production
Hodgkin's lymphoma
lung, breast, MM (these 3 most common)
Treatment
Remove Ca
Furosemide (do not use routinely), only for those with limited cardiopul capacity)
Reduce bone resorption and renal absorption
Bisphosphonates
Action: sustained decrease in Ca in 12~48h, last for 2~4 weeks
Calcitonin (limited role in malig): 4U/kg SC/IV, q12h
Action: lower Ca in 2~4h
SE: tachyphylaxis in 3 days, hypersensitivity response
Prednisone 60mg/d PO, may helpful in steroid-sen tumor, e.g. lymphoma, MM
Saline hydration (Ca is osmotic diuresis, and it usually happens in advanced cancer means cachexia) w/ 1~2L bolus, then 200~250cc/h IF
hemodialysis
SE: bisphosphonate-Ca complex deposition in kidney -> RF if given too rapidly
Hyponatremia
Causes
SIADH (euvolemic)
Treatment
mild >125
Manifestations
CNS
Seizure, usually GTC; survey for intracranial lesion if focal
water restriction to 500c/d
mod 110~125
Furosemide 0.5~1mg/kg PO + IV NS
severe <110 or seizure
3% saline at 25~100c/h
Adrenal insufficiency
Tumor lysis syndrome
Cytolysis -> release of intracellular substance
hyperkalemia
dysrhythmia
hyperP (malign cells had 4X increase of P) -> hypocalcemia
nucleic acid -> uric acid
urate precipitate in renal tubules
AKI
CaP crystal in renal tubes
AKI
Prophylaxis with allopurinol, hydration
seizure, tetanus
Prophylactic hydration; treat hyperP with dextrose and insulin; phosphate binder is limited
Hematologic derangement
Febrile neutropenia (nl N: 1500~8000): lack of localizing sign despite infection; postC/T neutropenia usually sig at D5~10, recover w/in D15
Clinical important: ANC<1000
Severe: ANC<500
Profound: ANC<100
Treatment
Disposition
hospitalization criteria
Expected profound neutropenia >7d
Multiple comorbidities
AKI, liver injury
Non low risk score: Multinational Association for Supportive Care in Cancer Risk Index or Clinical Index of Stable Febrile Neutropenia tool
Empirical abx if ANC<500; if ANC 500~1000 w/ risk factor for bac infection; >1000 limited evidence (median fever 2d for low risk, 5~7d for high risk after abx)
Pathogen
60% GPC
S.a, S. viridians, CONS, enterococcus
GNB
E.coli, KP, P.a
Add vancomycin if hemodynamic instability, radiographic pneumonia, catheter-related infection, skin or soft tissue infection, known coloniza- tion with resistant gram-positive organism
Hyperviscosity syndrome (normal plasma viscosity to water: 1.7~2.1; serum to water: 1.4~1.8; sx patients have serum viscosity >4
components
Hct >60%
WBC>100K
abnl plasma content
Waldenström’s macro- globulinemia and Ig A–producing myeloma
polycythermia
leukemia
Treatment
Hydration (dehydration exacerbates)
Plasmapheresis / Leukapharesis
VTE
Chemotherapy-related
Extravasation of C/T
C-spine mets common origin: Lung, breast, and prostate cancers and lymphoma and multiple myeloma